=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528461316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFUSION CENTERS OF AMERICA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16890 US HIGHWAY 441
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-315-1651
-----------------------------------------------------
Fax | 352-315-1703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16890 US HIGHWAY 441
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-315-1651
-----------------------------------------------------
Fax | 352-315-1703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAYMOND DOMINICK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 325-315-1651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------